April Oertle1, Justin Assioun2,3, Audrey Martin4, Mylinh Nguyen2,3.
1University of Illinois College of Medicine, Rockford, Illinois,
2Division of Emergency Medicine, Rady Children’s Hospital San Diego, San Diego, California,
3Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California,
4Rocky Vista University College of Osteopathic Medicine, Billings, Montana.
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Abstract
Unintentional ingestions are a leading cause of emergency department visits in young children, often presenting with nonspecific and potentially misleading clinical findings.
We report the case of a previously healthy 2-year-old female presenting with altered mental status, bradycardia, and hypothermia without a clear history of ingestion or environmental stressors. Initial evaluation for infectious, metabolic, and endocrine etiologies was unrevealing. Subsequent history identified possible access to a naphazoline-containing nasal decongestant obtained internationally. The patient was managed with supportive care, including active rewarming and cardiorespiratory monitoring, with complete clinical recovery within 24 hours.
This case highlights the importance of maintaining a broad toxicologic differential in pediatric patients with hypothermia and altered mental status, even without a witnessed exposure. Imidazoline toxicity should be considered in the appropriate clinical context, as early recognition can guide management, limit unnecessary interventions, and support favorable outcomes. Internationally sourced medications may vary significantly in formulation and labeling, complicating identification of toxic exposures. Awareness of this growing factor is critical for timely recognition, diagnosis, and appropriate management.
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